=====================================================
General NPI Number Information
=====================================================
NPI Number | 1841498722
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JENNIFER CHUNG M.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/03/2007
-----------------------------------------------------
Last Update Date | 09/22/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9250 BLUE ASH RD
-----------------------------------------------------
City | BLUE ASH
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45242-6822
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 513-792-7445
-----------------------------------------------------
Fax | 513-791-4042
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 237 WILLIAM HOWARD TAFT RD 2ND FL, CBO2-3, ATTN: CREDENTIALING
-----------------------------------------------------
City | CINCINNATI
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45219-2610
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 513-792-7441
-----------------------------------------------------
Fax | 513-791-4042
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208100000X
-----------------------------------------------------
Taxonomy Name | Physical Medicine & Rehabilitation Physician
-----------------------------------------------------
License Number | 268967
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208100000X
-----------------------------------------------------
Taxonomy Name | Physical Medicine & Rehabilitation Physician
-----------------------------------------------------
License Number | 46125
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 390200000X
-----------------------------------------------------
Taxonomy Name | Student in an Organized Health Care Education/Training Program
-----------------------------------------------------
License Number | 209100000X
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 208100000X
-----------------------------------------------------
Taxonomy Name | Physical Medicine & Rehabilitation Physician
-----------------------------------------------------
License Number | 35.121576
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------